Provider Demographics
NPI:1740206192
Name:FOSDICK, GORDON E (DPM)
Entity Type:Individual
Prefix:DR
First Name:GORDON
Middle Name:E
Last Name:FOSDICK
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:196 PARKWAY S
Mailing Address - Street 2:SUITE 304
Mailing Address - City:WATERFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06385-1234
Mailing Address - Country:US
Mailing Address - Phone:860-442-7027
Mailing Address - Fax:860-444-0074
Practice Address - Street 1:470 MAIN ST
Practice Address - Street 2:
Practice Address - City:MIDDLEFIELD
Practice Address - State:CT
Practice Address - Zip Code:06455-1210
Practice Address - Country:US
Practice Address - Phone:860-349-8500
Practice Address - Fax:860-349-3081
Is Sole Proprietor?:No
Enumeration Date:2006-07-15
Last Update Date:2013-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT00723213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT000723OtherCONNECTICARE
CT030000723CT05OtherBLUE CROSS BLUE SHIELD
CT004206951Medicaid
CTU79658Medicare UPIN
CT480000802Medicare PIN
CT030000723CT05OtherBLUE CROSS BLUE SHIELD